1
|
Suludere MA, Öz OK, Rogers LC, Wukich DK, Malone M, Lavery LA. MRSA infection, re-infection and clinical outcomes in diabetic foot infections. Wound Repair Regen 2024; 32:377-383. [PMID: 38419162 DOI: 10.1111/wrr.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/27/2024] [Accepted: 02/18/2024] [Indexed: 03/02/2024]
Abstract
The aim was to investigate methicillin-resistant Staphylococcus aureus (MRSA) incidence, conversion and outcomes in diabetic foot infections (DFIs). This is a pooled patient-level analysis of combined data sets from two randomised clinical trials including 219 patients admitted to the hospital with moderate or severe DFIs. Intraoperative bone and tissue cultures identified bacterial pathogens. We identified pathogens at index infections and subsequent re-infections. We identified MRSA conversion (MSSA to MRSA) in re-infections. MRSA incidence in index infections was 10.5%, with no difference between soft tissue infections (STIs) and osteomyelitis (OM). MRSA conversion occurred in 7.7% of the re-infections in patients who initially had MSSA in their cultures. Patients with re-infection were 2.2 times more likely to have MRSA compared to the first infection (10.5% vs. 25.8%, relative risk [RR] = 2.2, p = 0.001). Patients with MRSA had longer antibiotic treatment during the 1-year follow-up, compared to other pathogens (other 49.8 ± 34.7 days, MRSA 65.3 ± 41.5 days, p = 0.04). Furthermore, there were no differences in healing, time to heal, length of stay, re-infection, amputation, re-ulceration, re-admission, surgery after discharge and amputation after discharge compared to other pathogens. The incidence of MRSA at the index was 10.5% with no difference in STI and OM. MRSA incidence was 25.8% in re-infections. The RR of having MRSA was 2.2 times higher in re-infections. Patients with MRSA used more antibiotics during the 1-year follow-up. Furthermore, there were no differences in clinical outcomes compared to other bacterial pathogens.
Collapse
Affiliation(s)
- Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lee C Rogers
- Department of Orthopedic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Malone
- Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Liverpool, New South Wales, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Frazee BW. Diabetic Foot Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:267-285. [PMID: 38641391 DOI: 10.1016/j.emc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.
Collapse
Affiliation(s)
- Bradley W Frazee
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| |
Collapse
|
3
|
Liu J, Liu L, Li Y, Cai Z, Zhang H. Concordance of bone culture and deep tissue culture during the operation of diabetic foot osteomyelitis and clinical characteristics of patients. Eur J Trauma Emerg Surg 2023; 49:2579-2588. [PMID: 37561150 DOI: 10.1007/s00068-023-02342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE To retrospectively analyze the concordance of bacterial culture between bone tissue and deep soft tissue in diabetic foot osteomyelitis (DFO) patients and clinical characteristics of patients. METHODS This study collected samples from 155 patients with suspected DFO (who required amputation after clinical evaluation). Bacterial culture and drug susceptibility tests were performed on the patients' deep soft tissue and bone tissue, and the consistency between the two was compared. In addition, the differences among DFO patients with different degrees of infection were compared classified by the PEDIS classifications. RESULTS Among the 155 patients diagnosed with DFO, the positive rate of bone culture was 78.7% (122/155). This study cultured 162 strains, including 73 Gram-positive bacteria, 83 Gram-negative bacteria, and 6 fungi. Staphylococcus aureus (33 strains) was the most common bacteria. The overall agreement between bone culture and tissue culture was 42.8%, with Staphylococcus aureus and Enterobacteria having the best (64.3%) and least agreements (27.3%), respectively. The drug sensitivity results in bone culture showed that Staphylococcus aureus was the main Gram-positive bacteria. The bacteria were sensitive to linezolid and vancomycin. Proteus mirabilis was the main Gram-negative bacteria. These were more sensitive than biapenem and piperacillin/tazobactam. Fungi were more sensitive to voriconazole and itraconazole. CONCLUSION The culture results of deep soft tissues near the bone cannot accurately represent the true pathogen of DFO. For DFO patients, bone culture should be taken as much as possible, and appropriate antibiotics should be selected according to the drug susceptibility results.
Collapse
Affiliation(s)
- Jiawen Liu
- Department of Endocrinology, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Linlin Liu
- Department of Endocrinology, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Yantao Li
- Department of Endocrinology, People's Hospital of Henan University, Henan Provincial People's Hospital, Zhengzhou, 450003, China
| | - Zixin Cai
- Department of Endocrinology, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Huifeng Zhang
- Department of Endocrinology, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China.
| |
Collapse
|
4
|
Moore J, Gooday C, Soliman R, Dhatariya K. Reduction in the prevalence of methicillin-resistant Staphylococcus aureus in tissue and wound swab samples taken from outpatients attending a specialist diabetic foot clinic 2005-2021. Diabet Med 2023; 40:e15081. [PMID: 36883882 DOI: 10.1111/dme.15081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/03/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023]
Abstract
AIMS To assess annual change in prevalence of methicillin resistant Staphylococcus aureus (MRSA) from tissue and wound swab samples from foot ulcers (DFUs) in people with diabetes between 2005 and 2021. METHODS A retrospective analysis of everyone with MRSA positive wound or tissue swabs taken from our specialist multidisciplinary foot clinic between July 2005 and July 2021. RESULTS A total of 406 MRSA positive isolates from DFU swabs were identified from 185 individuals attending the foot clinic. There were 22 hospital-acquired infections (HAIs) and 159 community-acquired infections (CAIs). Fifty-two per cent (n = 37) of these individuals from 2010 to 2021 (n = 71) had presence of at least three risk factors for MRSA. The total number of swabs sent was 6312 from 1916 individuals living with diabetes. Annual MRSA DFU prevalence peaked in 2008 at 14.6% (n = 38), decreased in 2013 to 5.2% (n = 20) and did not exceed 4% (n = 6) from 2015 to 2021. Hospital MRSA was lowest in 2021 (n = 211), a 76% fall from 2007 (n = 880). Incidence of MRSA HAI from 2015 to 2021 ranged from 5.4% (n = 14) in 2020 to 11.5% (n = 41) in 2018. CONCLUSIONS Prevalence of MRSA in DFU infections treated as outpatients is decreasing in line with falls in hospital acquired blood-borne infections and with overall hospital MRSA incidence. This is likely a reflection of the combination of interventions, including stringent antibiotic prescribing and decolonisation strategies. Reduction in prevalence should have positive impact on outcomes in people living with diabetes, reducing the complication of osteomyelitis and necessity for long-term antibiotic administration.
Collapse
Affiliation(s)
- James Moore
- Department of Medicine, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Catherine Gooday
- Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Reham Soliman
- Department of Microbiology, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Ketan Dhatariya
- Department of Medicine, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
5
|
Soldevila-Boixader L, Murillo O, Waibel FWA, Huber T, Schöni M, Lalji R, Uçkay I. The Epidemiology of Antibiotic-Related Adverse Events in the Treatment of Diabetic Foot Infections: A Narrative Review of the Literature. Antibiotics (Basel) 2023; 12:antibiotics12040774. [PMID: 37107136 PMCID: PMC10135215 DOI: 10.3390/antibiotics12040774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The use of antibiotics for the treatment of diabetic foot infections (DFIs) over an extended period of time has been shown to be associated with adverse events (AEs), whereas interactions with concomitant patient medications must also be considered. The objective of this narrative review was to summarize the most frequent and most severe AEs reported in prospective trials and observational studies at the global level in DFI. Gastrointestinal intolerances were the most frequent AEs, from 5% to 22% among all therapies; this was more common when prolonged antibiotic administration was combined with oral beta-lactam or clindamycin or a higher dose of tetracyclines. The proportion of symptomatic colitis due to Clostridium difficile was variable depending on the antibiotic used (0.5% to 8%). Noteworthy serious AEs included hepatotoxicity due to beta-lactams (5% to 17%) or quinolones (3%); cytopenia's related to linezolid (5%) and beta-lactams (6%); nausea under rifampicin, and renal failure under cotrimoxazole. Skin rash was found to rarely occur and was commonly associated with the use of penicillins or cotrimoxazole. AEs from prolonged antibiotic use in patients with DFI are costly in terms of longer hospitalization or additional monitoring care and can trigger additional investigations. The best way to prevent AEs is to keep the duration of antibiotic treatment short and with the lowest dose clinically necessary.
Collapse
Affiliation(s)
- Laura Soldevila-Boixader
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Oscar Murillo
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Tanja Huber
- Hospital Pharmacy, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Rahim Lalji
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, 8008 Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| |
Collapse
|
6
|
Influence of Skin Commensals on Therapeutic Outcomes of Surgically Debrided Diabetic Foot Infections-A Large Retrospective Comparative Study. Antibiotics (Basel) 2023; 12:antibiotics12020316. [PMID: 36830227 PMCID: PMC9952192 DOI: 10.3390/antibiotics12020316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
In diabetic foot infections (DFI), the clinical virulence of skin commensals are generally presumed to be low. In this single-center study, we divided the wound isolates into two groups: skin commensals (coagulase-negative staphylococci, micrococci, corynebacteria, cutibacteria) and pathogenic pathogens, and followed the patients for ≥ 6 months. In this retrospective study among 1018 DFI episodes (392 [39%] with osteomyelitis), we identified skin commensals as the sole culture isolates (without accompanying pathogenic pathogens) in 54 cases (5%). After treatment (antibiotic therapy [median of 20 days], hyperbaric oxygen in 98 cases [10%]), 251 episodes (25%) were clinical failures. Group comparisons between those growing only skin commensals and controls found no difference in clinical failure (17% vs. 24 %, p = 0.23) or microbiological recurrence (11% vs. 17 %, p = 0.23). The skin commensals were mostly treated with non-beta-lactam oral antibiotics. In multivariate logistic regression analysis, the isolation of only skin commensals was not associated with failure (odds ratio 0.4, 95% confidence interval 0.1-3.8). Clinicians might wish to consider these isolates as potential pathogens when selecting a targeted antibiotic regimen, which may also be based on oral non-beta-lactam antibiotic agents effective against the corresponding skin pathogens.
Collapse
|
7
|
Moderate to Severe Soft Tissue Diabetic Foot Infections: A Randomized, Controlled, Pilot Trial of Post-debridement Antibiotic Treatment for 10 versus 20 days. Ann Surg 2022; 276:233-238. [PMID: 35623048 PMCID: PMC9259031 DOI: 10.1097/sla.0000000000005205] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal duration of antibiotic therapy for soft-tissue infections of the diabetic foot remains unknown. OBJECTIVE We determine if antibiotic therapy after debridement for a short (10 days), compared with a long (20 days), duration for soft-tissue infections of the diabetic foot results in similar rates of clinical remission and adverse events (AE). SUMMARY OF BACKGROUND DATA The optimal duration of systemic antibiotic therapy, after successful debridement, for soft tissue infections of diabetic patients is unknown. Because of the high recurrence risk, overuse is commonplace. METHODS This was a randomized, controlled, non-inferiority pilot trial of cases of diabetic foot infection (excluding osteomyelitis) with the primary outcome of "clinical remission at 2-months follow-up". RESULTS Among 66 enrolled episodes (17% females; median age 71 years), we randomized 35 to the 10-day arm and 31 to the 20-day arm. The median duration of the parenteral antibiotic therapy was 1 day, with the remainder given orally. In the intention-to-treat population, we achieved clinical remission in 27 (77%) patients in the 10-day arm compared to 22 (71%) in the 20-days arm ( P = 0.57). There were a similar proportion in each arm of AE (14/35 versus 11/31; P = 0.71), and remission in the per-protocol population (25/32 vs 18/27; P = 0.32). Overall, 8 soft tissue DFIs in the 10-day arm and 5 cases in the 20-day arm recurred as a new osteomyelitis [8/35 (23%) versus 5/31 (16%); P = 0.53]. Overall, the number of recurrences limited to the soft tissues was 4 (6%). By multivariate analysis, rates of remission (intention-to-treat population, hazard ratio 0.6, 95%CI 0.3-1.1; per-protocol population 0.8, 95%CI 0.4-1.5) and AE were not significantly different with a 10-day compared to 20-day course. CONCLUSIONS In this randomized, controlled pilot trial, post-debridement antibiotic therapy for soft tissue DFI for 10 days gave similar (and non-inferior) rates of remission and AEs to 20 days. A larger confirmatory trial is under way. TRIAL REGISTRATION ClinicalTrials NCT03615807.
Collapse
|
8
|
Durand BARN, Pouget C, Magnan C, Molle V, Lavigne JP, Dunyach-Remy C. Bacterial Interactions in the Context of Chronic Wound Biofilm: A Review. Microorganisms 2022; 10:microorganisms10081500. [PMID: 35893558 PMCID: PMC9332326 DOI: 10.3390/microorganisms10081500] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic wounds, defined by their resistance to care after four weeks, are a major concern, affecting millions of patients every year. They can be divided into three types of lesions: diabetic foot ulcers (DFU), pressure ulcers (PU), and venous/arterial ulcers. Once established, the classical treatment for chronic wounds includes tissue debridement at regular intervals to decrease biofilm mass constituted by microorganisms physiologically colonizing the wound. This particular niche hosts a dynamic bacterial population constituting the bed of interaction between the various microorganisms. The temporal reshuffle of biofilm relies on an organized architecture. Microbial community turnover is mainly associated with debridement (allowing transitioning from one major representant to another), but also with microbial competition and/or collaboration within wounds. This complex network of species and interactions has the potential, through diversity in antagonist and/or synergistic crosstalk, to accelerate, delay, or worsen wound healing. Understanding these interactions between microorganisms encountered in this clinical situation is essential to improve the management of chronic wounds.
Collapse
Affiliation(s)
- Benjamin A. R. N. Durand
- Bacterial Virulence and Chronic Infections, UMR 1047, Université Montpellier, INSERM, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, 30908 Nîmes, France; (B.A.R.N.D.); (C.P.); (C.M.); (J.-P.L.)
| | - Cassandra Pouget
- Bacterial Virulence and Chronic Infections, UMR 1047, Université Montpellier, INSERM, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, 30908 Nîmes, France; (B.A.R.N.D.); (C.P.); (C.M.); (J.-P.L.)
| | - Chloé Magnan
- Bacterial Virulence and Chronic Infections, UMR 1047, Université Montpellier, INSERM, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, 30908 Nîmes, France; (B.A.R.N.D.); (C.P.); (C.M.); (J.-P.L.)
| | - Virginie Molle
- Laboratory of Pathogen Host Interactions, Université de Montpellier, CNRS, UMR 5235, 34000 Montpellier, France;
| | - Jean-Philippe Lavigne
- Bacterial Virulence and Chronic Infections, UMR 1047, Université Montpellier, INSERM, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, 30908 Nîmes, France; (B.A.R.N.D.); (C.P.); (C.M.); (J.-P.L.)
| | - Catherine Dunyach-Remy
- Bacterial Virulence and Chronic Infections, UMR 1047, Université Montpellier, INSERM, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, 30908 Nîmes, France; (B.A.R.N.D.); (C.P.); (C.M.); (J.-P.L.)
- Correspondence: ; Tel.: +33-466-683-202
| |
Collapse
|
9
|
Membrane acting Povarov-Doebner derived compounds potently disperse preformed multidrug resistant Gram-positive bacterial biofilms. Eur J Med Chem 2022; 240:114550. [DOI: 10.1016/j.ejmech.2022.114550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022]
|
10
|
Uçkay I, Lebowitz D, Kressmann B, von Dach E, Lipsky BA, Gariani K. Pseudomonal Diabetic Foot Infections: Vive la Différence? Mayo Clin Proc Innov Qual Outcomes 2022; 6:250-256. [PMID: 35634135 PMCID: PMC9130228 DOI: 10.1016/j.mayocpiqo.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the outcomes of diabetic foot infections (DFIs) due to Pseudomonas aeruginosa. Patients and Methods From April 24, 2013 to July 31, 2016, we analyzed data from patients prospectively enrolled in our clinical pathway of DFIs, comparing those with infection due to Pseudomonas with those without infection due to Pseudomonas. Results Overall, we assessed 1018 cases of DFIs: 392 with osteomyelitis and 626 with only soft tissue infections. The prevalence of P aeruginosa in deep wound cultures was 10% (104/1018); of the 1018 cultures, 22 were monomicrobial, 82 were polymicrobial, and 46 were with osteomyelitis. Overall, the patients were treated with a median of 1 surgical debridement and a total of 20 days of antibiotic therapy. In a comparison of crude groups, the proportion of clinical failures was significantly higher with Pseudomonas than with other pathogens (36/104 [35%] vs 218/914 [24%], respectively; P=.02). A multivariate analysis showed that pseudomonal DFIs did not recur more often than nonpseudomonal DFIs (hazard ratio, 1.0; 95% confidence interval, 0.6-1.7). Among the 104 cases of pseudomonal DFIs, there was no association between failure of treatment and the total duration of antibiotic therapy, duration of intravenous therapy, duration of combined antibiotic therapy with more than 1 agent, or duration of oral (fluoroquinolone) therapy. Among 15 cases of pseudomonal recurrence, 2 (13%) developed resistance to the antibiotic agent used for the index episode. Conclusion For DFIs caused by P aeruginosa, other than choosing an antibiotic agent that is active against the organism, it does not appear necessary to treat with a different therapeutic regimen compared with the treatment of nonpseudomonal DFIs. There is no difference!
Collapse
Affiliation(s)
- Ilker Uçkay
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
- Correspondence: Address to Ilker Uçkay, MD, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Dan Lebowitz
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A. Lipsky
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, University of Washington, Seattle, WA
| | - Karim Gariani
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Division of Endocrinology, Diabetes, Nutrition and Therapeutic Patient Education, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
11
|
Maurer S, Hepp Z, McCallin S, Waibel F, Romero F, Zorman Y, Lipsky B, Uçkay İ. Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge. J Bone Jt Infect 2022; 7:61-70. [PMID: 35415069 PMCID: PMC8990364 DOI: 10.5194/jbji-7-61-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.
Collapse
Affiliation(s)
- Steven M. Maurer
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Zehra S. Hepp
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Shawna McCallin
- Clinical and Phage Research, Balgrist University Hospital, University
of Zurich, Zurich, Switzerland
| | - Felix W. A. Waibel
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Federico C. Romero
- Department of Infectious Diseases, Sanatorio
Allende Hospital, Córdoba, Argentina
| | - Yılmaz Zorman
- Cardiovascular Surgery Department, Koç University Hospital,
Istanbul, Turkey
| | | | - İlker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich,
Switzerland
| |
Collapse
|
12
|
Hung SY, Chiu CH, Huang CH, Lin CW, Yeh JT, Yang HM, Huang YY. Impact of wound microbiology on limb preservation in patients with diabetic foot infection. J Diabetes Investig 2021; 13:336-343. [PMID: 34418309 PMCID: PMC8847138 DOI: 10.1111/jdi.13649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 07/26/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS/INTRODUCTION To investigate the association between specific bacterial pathogens and treatment outcome in patients with limb-threatening diabetic foot infection (LT-DFI). MATERIALS AND METHODS Consecutive patients treated for LT-DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 and 2017. Patients with positive wound culture results at first aid were enrolled. Clinical factors, laboratory data, and wound culture results were compared. Lower-extremity amputations and in-hospital mortality were defined as a poor outcome. RESULTS Among the 558 patients, 272 (48.7%) patients had lower extremity amputation and 22 (3.9%) patients had in-hospital mortality. Gram-negative bacterial (GNB) infection was the independent factor following factors adjustment. When all the 31 microorganisms were analyzed, only E. coli (adjusted odds ratio [aOR], 3.01; 95% CI, 1.60-5.65), Proteus spp. (aOR, 2.99; 95% CI, 1.69-5.29), and Pseudomonas aeruginosa (aOR, 2.00; 95% CI 1.20-3.32) were associated with poor outcome. The analysis of specific GNB species in association with major- or minor- amputation have been reported. No specific pathogen was associated with cause of death in patients with mortality within 30 days. The antimicrobial-resistant strains were not associated with a poor treatment outcome. CONCLUSIONS The presence of GNB was associated with limb amputations. This study provides insight into more timely and appropriate management of the diabetic foot infection.
Collapse
Affiliation(s)
- Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jiun-Ting Yeh
- Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Hui-Mei Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| |
Collapse
|
13
|
Macdonald KE, Boeckh S, Stacey HJ, Jones JD. The microbiology of diabetic foot infections: a meta-analysis. BMC Infect Dis 2021; 21:770. [PMID: 34372789 PMCID: PMC8351150 DOI: 10.1186/s12879-021-06516-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/28/2021] [Indexed: 01/13/2023] Open
Abstract
Background Diabetic foot ulcers are a common complication of poorly controlled diabetes and often become infected, termed diabetic foot infection. There have been numerous studies of the microbiology of diabetic foot infection but no meta-analysis has provided a global overview of these data. This meta-analysis aimed to investigate the prevalence of bacteria isolated from diabetic foot infections using studies of any design which reported diabetic foot infection culture results. Methods The Medline, EMBASE, Web of Science and BIOSIS electronic databases were searched for studies published up to 2019 which contained microbiological culture results from at least 10 diabetic foot infection patients. Two authors independently assessed study eligibility and extracted the data. The main outcome was the prevalence of each bacterial genera or species. Results A total of 112 studies were included, representing 16,159 patients from which 22,198 microbial isolates were obtained. The organism most commonly identified was Staphylococcus aureus, of which 18.0% (95% CI 13.8–22.6%; I2 = 93.8% [93.0–94.5%]) was MRSA. Other highly prevalent organisms were Pseudomonas spp., E. coli and Enterococcus spp. A correlation was identified between Gross National Income and the prevalence of Gram positive or negative organisms in diabetic foot infections. Conclusion The microbiology of diabetic foot infections is diverse, but S. aureus predominates. The correlation between the prevalence of Gram positive and negative organisms and Gross National Income could reflect differences in healthcare provision and sanitation. This meta-analysis has synthesised multiple datasets to provide a global overview of the microbiology of diabetic foot infections that will help direct the development of novel therapeutics. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06516-7.
Collapse
Affiliation(s)
- Katherine E Macdonald
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Sophie Boeckh
- Faculty of Medicine and Health Sciences, McGill University, 3605 Rue de la Montagne, Montreal, QC, H3G 2M1, Canada
| | - Helen J Stacey
- Edinburgh Medical School, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Joshua D Jones
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| |
Collapse
|
14
|
Saltoglu N, Surme S, Ezirmik E, Kadanali A, Kurt AF, Sahin Ozdemir M, Ak O, Altay FA, Acar A, Cakar ZS, Tulek N, Kinikli S. The Effects of Antimicrobial Resistance and the Compatibility of Initial Antibiotic Treatment on Clinical Outcomes in Patients With Diabetic Foot Infection. INT J LOW EXTR WOUND 2021; 22:283-290. [PMID: 33856261 DOI: 10.1177/15347346211004141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We aimed to determine pathogen microorganisms, their antimicrobial resistance patterns, and the effect of initial treatment on clinical outcomes in patients with diabetic foot infection (DFI). Patients with DFI from 5 centers were included in this multicenter observational prospective study between June 2018 and June 2019. Multivariate analysis was performed for the predictors of reinfection/death and major amputation. A total of 284 patients were recorded. Of whom, 193 (68%) were male and the median age was 59.9 ± 11.3 years. One hundred nineteen (41.9%) patients had amputations, as the minor (n = 83, 29.2%) or major (n = 36, 12.7%). The mortality rate was 1.7% with 4 deaths. A total of 247 microorganisms were isolated from 200 patients. The most common microorganisms were Staphylococcus aureus (n = 36, 14.6%) and Escherichia coli (n = 32, 13.0%). Methicillin resistance rates were 19.4% and 69.6% in S aureus and coagulase-negative Staphylococcus spp., respectively. Multidrug-resistant Pseudomonas aeruginosa was detected in 4 of 22 (18.2%) isolates. Extended-spectrum beta-lactamase-producing Gram-negative bacteria were detected in 20 (38.5%) isolates of E coli (14 of 32) and Klebsiella spp. (6 of 20). When the initial treatment was inappropriate, Klebsiella spp. related reinfection within 1 to 3 months was observed more frequently. Polymicrobial infection (p = .043) and vancomycin treatment (p = .007) were independent predictors of reinfection/death. Multivariate analysis revealed vascular insufficiency (p = .004), hospital readmission (p = .009), C-reactive protein > 130 mg/dL (p = .007), and receiving carbapenems (p = .005) as independent predictors of major amputation. Our results justify the importance of using appropriate narrow-spectrum empirical antimicrobials because higher rates of reinfection and major amputation were found even in the use of broad-spectrum antimicrobials.
Collapse
Affiliation(s)
- Nese Saltoglu
- 64298Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serkan Surme
- 64298Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Ayten Kadanali
- Biruni University, Medical School, Istanbul, Turkey.,University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
| | | | | | - Oznur Ak
- 485519Dumlupinar University, Kutahya, Turkey.,University of Health Sciences, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Fatma Aybala Altay
- 52945University of Health Sciences, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Ali Acar
- 52945University of Health Sciences, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey.,Atilim University, Ankara, Turkey
| | - Zeynep Sule Cakar
- University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Necla Tulek
- Atilim University, Ankara, Turkey.,University of Health Sciences, Ankara Education and Research Hospital, Ankara, Turkey
| | - Sami Kinikli
- University of Health Sciences, Ankara Education and Research Hospital, Ankara, Turkey
| | | |
Collapse
|
15
|
Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
Collapse
Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| |
Collapse
|
16
|
Tayebi Z, Fazeli M, Hashemi A, Abdi S, Dadashi M, Nasiri MJ, Goudarzi M. Molecular characterization of invasive Staphylococcus aureus strains isolated from patients with diabetes in Iran: USA300 emerges as the major type. INFECTION GENETICS AND EVOLUTION 2020; 87:104679. [PMID: 33326876 DOI: 10.1016/j.meegid.2020.104679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/29/2020] [Accepted: 12/11/2020] [Indexed: 01/04/2023]
Abstract
There have been few studies focused on the molecular characterization of invasive Staphylococcus aureus strains in patients with diabetes in Iran. In the present study, 20 invasive S. aureus strains recovered from the patients with diabetes characterized by the virulence and resistance analysis, biofilm formation, staphylocoagulase (SC) typing, S. aureus protein A locus (spa) typing staphylococcal cassette chromosome mec (SCCmec) typing, and multilocus sequence typing (MLST). Virulence gene detection indicated a high prevalence of strains encoding the pvl genes (50%), a low prevalence of the tst and seg gene (each of them was 5%) and a markedly high prevalence of fnbB (95%), fnbA (85%), icaD (75%), icaA (65%). A total of 3 coagulase types (III, 85%; II, 10%; V, 5%), 2 agr types (I, 90%; II 10%) and 2 SCCmec types (IV, 65%; III, 35%) and four different clones namely ST8-MRSA-IV/t008 (50%) (USA300), ST239-MRSA-III/t030 (35%), ST5-MRSA-IV/t002 (10%), and ST45-MRSA-IV/t038 (5%) were detected in this study. Eighty-five percent of the isolates were biofilm producers. All the 4 high-level mupirocin resistance (HLMUPR) strains belonged to CC/ST8-MRSA-IV/t008 clone and carried mupA gene. Fusidic acid-resistant isolate belonged to ST239-SCCmec III/t030 clone. One vancomycin-intermediate resistance isolates was detected in our study, which belonged to ST5-MRSA-IVt002. Circulating clone in MRSA strains (USA300) isolated from the patients with diabetes highlighting the possibility of transmission of these microorganisms' clones between hospital, community, and environments. However, further studies require providing critical insights into the importance of continued controlling and treatment of S. aureus infections in patients with diabetes.
Collapse
Affiliation(s)
- Zahra Tayebi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Microbiology, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Maryam Fazeli
- Department of Virology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ali Hashemi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Abdi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Tehran, Iran
| | - Masoud Dadashi
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
17
|
Gariani K, Pham TT, Kressmann B, Jornayvaz FR, Gastaldi G, Stafylakis D, Philippe J, Lipsky BA, Uçkay İ. Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial. Clin Infect Dis 2020; 73:e1539-e1545. [PMID: 33242083 DOI: 10.1093/cid/ciaa1758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE). METHODS In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%). RESULTS Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4). CONCLUSIONS In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.
Collapse
Affiliation(s)
- Karim Gariani
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Truong-Thanh Pham
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - François R Jornayvaz
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Giacomo Gastaldi
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jacques Philippe
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - İlker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland.,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
18
|
Pessoa E Costa T, Duarte B, João AL, Coelho M, Formiga A, Pinto M, Neves J. Multidrug-resistant bacteria in diabetic foot infections: Experience from a portuguese tertiary centre. Int Wound J 2020; 17:1835-1839. [PMID: 32820614 PMCID: PMC7948579 DOI: 10.1111/iwj.13473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 12/30/2022] Open
Abstract
In recent years, the emergence of antibiotic resistant pathogens made increasingly difficult to establish appropriate empiric antimicrobial therapy protocols for acute diabetic foot infection (DFI) treatment. Early recognition of the population at-risk for multidrug-resistant (MDR) bacterial infection is of paramount importance in order to decrease large-spectrum antibiotic overuse. This study used retrospective cohort study in a multidisciplinary tertiary diabetic foot unit. Patients with severe DFI were included and divided according to their infection resistance profile (susceptible vs MDR bacteria). Data regarding their comorbidities and length of hospital stay were collected. The primary endpoint was to determine the risk factors for MDR infections and to evaluate if these were associated with an increased length of stay (LOS). A total of 112 microbial isolates were included. Predominance of Gram-positive bacteria was observed and 22.3% of isolated bacteria were MDR. Previous hospitalisation was associated with a higher likelihood of MDR infection. MDR bacterial infection was also associated with an increased LOS (P = .0296). Our study showed a high incidence of MDR bacteria in patients with a DFI, especially in those who had a recent hospitalisation. MDR infections were associated with a prolonged LOS and represent a global public health issue for which emergent measures are needed.
Collapse
Affiliation(s)
- Tomás Pessoa E Costa
- Dermatology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Bruno Duarte
- Dermatology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Luísa João
- Dermatology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Miguel Coelho
- Dermatology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Formiga
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Margarida Pinto
- Microbiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - José Neves
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| |
Collapse
|
19
|
Henig O, Pogue JM, Martin E, Hayat U, Ja'ara M, Kilgore PE, Cha R, Dhar S, Kaye KS. The Impact of Multidrug-Resistant Organisms on Outcomes in Patients With Diabetic Foot Infections. Open Forum Infect Dis 2020; 7:ofaa161. [PMID: 32500092 PMCID: PMC7255643 DOI: 10.1093/ofid/ofaa161] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background Multidrug-resistant organisms (MDROs) are important diabetic foot infection (DFI) pathogens. This study evaluated the impact of DFIs associated with MDRO pathogens (DFI-MDRO) on clinical outcomes. Methods Adults admitted to Detroit Medical Center from January 2012 to December 2015 with culture-positive DFI were included. Associations between outcomes and DFI-MDRO (evaluated as a single group that included methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant enterococci, Enterobacteriaceae resistant to third-generation cephalosporin [3GCR-EC], Acinetobacter baumannii, and Pseudomonas aeruginosa) were analyzed. Outcomes included above- and below-knee lower extremity amputation (LEA), readmissions, and mortality within a year after DFI. A propensity score predicting the likelihood of having DFI-MDRO was computed by comparing patients with DFI-MDRO with patients with DFI with non-MDRO pathogens (DFI-non-MDRO). Using conditional logistic regression, DFI-MDRO was analyzed as an independent variable after patients in the MDRO and non-MDRO groups were matched by propensity score. Results Six hundred forty-eight patients were included, with a mean age ± SD of 58.4 ± 13.7. Most patients in the cohort presented with chronic infection (75%). DFI-MDRO occurred in greater than one-half of the cohort (n = 364, 56%), and MRSA was the most common MDRO (n = 224, 62% of the DFI-MDRO group). In propensity-matched analyses, DFI-MDRO was not associated with 1-year LEA or readmissions, but was associated with recurrent DFI episodes (odds ratio, 2.1; 95% confidence interval, 1.38-3.21). Conclusions DFI-MDRO was associated with a 2-fold increased risk of recurrent DFI compared with patients with DFI-non-MDRO.
Collapse
Affiliation(s)
- Oryan Henig
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Jason M Pogue
- Department of Pharmacy Services, Sinai-Grace Hospital, Detroit Medical Center, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Emily Martin
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Umar Hayat
- Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan, USA
| | - Mahmoud Ja'ara
- Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan, USA
| | - Paul E Kilgore
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Raymond Cha
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sorab Dhar
- Division of Infectious Diseases, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
20
|
Ertuğrul B, Uçkay I, Schöni M, Peter-Riesch B, Lipsky BA. Management of diabetic foot infections in the light of recent literature and new international guidelines. Expert Rev Anti Infect Ther 2020; 18:293-305. [PMID: 32052672 DOI: 10.1080/14787210.2020.1730177] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: In May 2019 the International Working Group on the Diabetic Foot (IWGDF) launched their quadrennially updated guidelines on the management of diabetic foot infections (DFIs). Concomitantly, the number of new publications regarding DFI increased.Areas covered: The IWGDF committee developed and addressed key questions and produced evidence-based recommendations related to diagnosing and treating DFIs. This narrative review provides an overview of this new guideline and also of other recently published literature in the field of DFIs.Expert opinion: The 2019 IWGDF guidelines provide an authoritative, international, evidence-based approach to diagnosing and treating DFIs. The 27 recommendations are supported by systematic reviews of both diagnosis and interventions. Our review of this guideline, along with other recent publications in the field, allows us to offer state-of-the-art guidance for caring for these difficult infections. As the evidence base for management of DFIs remains suboptimal, we need further research to improve the management of DFIs.
Collapse
Affiliation(s)
- Bülent Ertuğrul
- Infectious Diseases and Clinical Microbiology, Adnan Menderes University, Aydın, Turkey
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Madlaina Schöni
- Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | | | | |
Collapse
|
21
|
Waibel F, Berli M, Catanzaro S, Sairanen K, Schöni M, Böni T, Burkhard J, Holy D, Huber T, Bertram M, Läubli K, Frustaci D, Rosskopf A, Botter S, Uçkay I. Optimization of the antibiotic management of diabetic foot infections: protocol for two randomized controlled trials. Trials 2020; 21:54. [PMID: 31915048 PMCID: PMC6950867 DOI: 10.1186/s13063-019-4006-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Few studies have addressed the appropriate duration of antibiotic therapy for diabetic foot infections (DFI) with or without amputation. We will perform two randomized clinical trials (RCTs) to reduce the antibiotic use and associated adverse events in DFI. METHODS We hypothesize that shorter durations of postdebridement systemic antibiotic therapy are noninferior (10% margin, 80% power, alpha 5%) to existing (long) durations and we will perform two unblinded RCTs with a total of 400 DFI episodes (randomization 1:1) from 2019 to 2022. The primary outcome for both RCTs is remission of infection after a minimal follow-up of 2 months. The secondary outcomes for both RCTs are the incidence of adverse events and the overall treatment costs. The first RCT will allocate the total therapeutic amputations in two arms of 50 patients each: 1 versus 3 weeks of antibiotic therapy for residual osteomyelitis (positive microbiological samples of the residual bone stump); or 1 versus 4 days for remaining soft tissue infection. The second RCT will randomize the conservative approach (only surgical debridement without in toto amputation) in two arms with 50 patients each: 10 versus 20 days of antibiotic therapy for soft tissue infections; and 3 versus 6 weeks for osteomyelitis. All participants will have professional wound debridement, adequate off-loading, angiology evaluation, and a concomitant surgical, re-educational, podiatric, internist and infectiology care. During the surgeries, we will collect tissues for BioBanking and future laboratory studies. DISCUSSION Both parallel RCTs will respond to frequent questions regarding the duration of antibiotic use in the both major subsets of DFIs, to ensure the quality of care, and to avoid unnecessary excesses in terms of surgery and antibiotic use. TRIAL REGISTRATION ClinicalTrials.gov, NCT04081792. Registered on 4 September 2019.
Collapse
Affiliation(s)
- Felix Waibel
- Team Technical Orthopedics, Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Berli
- Team Technical Orthopedics, Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Sabrina Catanzaro
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Kati Sairanen
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Madlaina Schöni
- Team Technical Orthopedics, Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Thomas Böni
- Team Technical Orthopedics, Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| | - Tanja Huber
- Hospital Pharmacy, Balgrist University Hospital, Zurich, Switzerland
| | - Maik Bertram
- Nursing Department, Balgrist University Hospital, Zurich, Switzerland
| | - Karin Läubli
- Physiotherapy, Balgrist University Hospital, Zurich, Switzerland
| | - Dario Frustaci
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland.,BioBanking, Balgrist Campus AG, Balgrist University Hospital, Zurich, Switzerland
| | - Andrea Rosskopf
- Radiology, Balgrist University Hospital, Zurich, Switzerland
| | - Sander Botter
- BioBanking, Balgrist Campus AG, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland. .,Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| |
Collapse
|
22
|
Bacterial Diversity of Diabetic Foot Ulcers: Current Status and Future Prospectives. J Clin Med 2019; 8:jcm8111935. [PMID: 31717640 PMCID: PMC6912738 DOI: 10.3390/jcm8111935] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 02/08/2023] Open
Abstract
Diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs) are associated with reduced patient quality of life, lower-extremity amputation, hospitalization, and high morbidity and mortality. Diverse bacterial communities have been identified in DFUs/DFIs, playing a significant role in infection prognosis. However, due to the high heterogeneity of bacterial communities colonized in DFUs/DFIs, culture-based methods may not isolate all of the bacterial population or unexpected microorganisms. Recently, high sensitivity and specificity of DNA (metagenomics) and RNA (metatranscriptomics) technologies have addressed limitations of culture-based methods and have taken a step beyond bacterial identification. As a consequence, new advances obtained from DNA- and RNA-based techniques for bacterial identification can improve therapeutic approaches. This review evaluated the current state of play in aetiology of DFUs/DFIs on culture and molecular approaches, and discussed the impact of metagenomic and metatranscriptomic methods in bacterial identification approaches.
Collapse
|
23
|
Chastain CA, Klopfenstein N, Serezani CH, Aronoff DM. A Clinical Review of Diabetic Foot Infections. Clin Podiatr Med Surg 2019; 36:381-395. [PMID: 31079605 DOI: 10.1016/j.cpm.2019.02.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
"Diabetic foot infections (DFIs) are a common cause of morbidity and mortality. This article summarizes current knowledge regarding DFI epidemiology, disease pathogenesis, and the impact of antimicrobial resistance among DFI. An evidence-based approach to clinical assessment, diagnosing osteomyelitis, as well as medical and surgical treatment is discussed, including a review of empiric and directed antibiotic treatment recommendations. The current state and needs of the clinical literature are identified throughout, with a discussion of the supporting role of infectious diseases specialists as well as future directions of the field."
Collapse
Affiliation(s)
- Cody A Chastain
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA
| | - Nathan Klopfenstein
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA
| | - Carlos H Serezani
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA. https://twitter.com/HSerezani
| | - David M Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA.
| |
Collapse
|
24
|
Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
Collapse
Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| |
Collapse
|
25
|
Gariani K, Lebowitz D, von Dach E, Kressmann B, Lipsky BA, Uçkay I. Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors. Diabetes Obes Metab 2019; 21:244-251. [PMID: 30129109 DOI: 10.1111/dom.13507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
AIM To determine the most appropriate duration of antibiotic therapy for diabetic foot infections (DFIs). METHODS Using a clinical pathway for adult patients with DFIs (retrospective cohort analysis), we created a cluster-controlled Cox regression model to assess factors related to remission of infection, emphasizing antibiotic-related variables. We excluded total amputations as a result of DFI and DFI episodes with a follow-up time of <2 months. RESULTS Among 1018 DFI episodes in 482 patients, we identified 392 episodes of osteomyelitis, 626 soft tissue infections, 246 large abscesses, 322 episodes of cellulitis and 335 episodes of necrosis; 313 cases involved revascularization. Patients underwent surgical debridement for 824 episodes (81%), of which 596 (59%) required amputation. The median total duration of antibiotic therapy was 20 days. After a median follow-up of 3 years, 251 of the episodes (24.7%) were followed by ≥1 additional episode(s). Comparing patients with and without additional episodes, risk of recurrence was lower in those who underwent amputation, had type 1 diabetes, or underwent revascularization. On multivariate analysis including the entire study population, risk of remission was inversely associated with type 1 diabetes (hazard ratio [HR] 0.3, 95% confidence interval [CI] 0.2-0.6). Neither duration of antibiotic therapy nor parenteral treatment affected risk of recurrence (HR 1.0, 95% CI 0.99-1.01 for both). Similarly, neither >3 weeks versus <3 weeks of therapy, nor >1 week versus <1 week of intravenous treatment affected recurrence. In stratified analyses for both soft tissue DFIs or osteomyelitis separately, we did not observe associations of antibiotic duration with microbiological or clinical recurrences of DFI. The HRs were 1.0 (95% CI 0.6-1.8) for an antibiotic duration >3 weeks overall and 0.6 (95% CI 0.2-1.3) for osteomyelitis cases only. Plotting of duration of antibiotic therapy failed to identify any optimal threshold for preventing recurrences. CONCLUSIONS Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.
Collapse
Affiliation(s)
- Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dan Lebowitz
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
26
|
Ghotaslou R, Memar MY, Alizadeh N. Classification, microbiology and treatment of diabetic foot infections. J Wound Care 2018; 27:434-441. [PMID: 30016139 DOI: 10.12968/jowc.2018.27.7.434] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diabetic foot ulcers (DFUs) are a common complication of type-1 and type-2 diabetes. About 10-15% of patients with diabetes develop foot ulcers. A validated foot ulcer classification system that will support the development of treatment strategis is necessary for clinicians managing DFUs. More than 10 classification systems have been described by researchers. Another important aspect of the management of DFUs is the proper identification of causative pathogens that trigger infections. While conventional diagnostic methods, such as swabs, cultures and biopsies are more widely used, novel molecular techniques have been exploring bacterial identification and quantification. Knowledge of the microbial aetiologies in diabetic foot infections, and understanding of antibiotic resistance, is critical for the effective management and treatment of these infected wounds. Initial antibiotic regimens are usually selected empirically. A set of common principles may help avoid selecting either an unnecessarily broad or inappropriately narrow antibiotic treatment regimen. In this review we provide a comprehensive summary and description of classification systems of diabetic foot infections, and a comprehensive discussion of microbiology.
Collapse
Affiliation(s)
- Reza Ghotaslou
- Professor of Medical Microbiology; Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Yousef Memar
- Candidate of Medical Bacteriology; Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Alizadeh
- Candidate of Medical Bacteriology; Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
27
|
Tuchscherr L, Korpos È, van de Vyver H, Findeisen C, Kherkheulidze S, Siegmund A, Deinhardt-Emmer S, Bach O, Rindert M, Mellmann A, Sunderkötter C, Peters G, Sorokin L, Löffler B. Staphylococcus aureus requires less virulence to establish an infection in diabetic hosts. Int J Med Microbiol 2018; 308:761-769. [PMID: 29843979 DOI: 10.1016/j.ijmm.2018.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/16/2018] [Accepted: 05/21/2018] [Indexed: 01/12/2023] Open
Abstract
Staphylococcus aureus is the most frequent pathogen causing diabetic foot infections. Here, we investigated the degree of bacterial virulence required to establish invasive tissue infections in diabetic organisms. Staphylococcal isolates from diabetic and non-diabetic foot ulcers were tested for their virulence in in vitro functional assays of host cell invasion and cytotoxicity. Isolates from diabetes mellitus type I/II patients exhibited less virulence than isolates from non-diabetic patients, but were nevertheless able to establish severe infections. In some cases, non-invasive isolates were detected deep within diabetic wounds, even though the strains were non-pathogenic in cell culture models. Testing of defined isolates in murine footpad injection models revealed that both low- and high-virulent bacterial strains persisted in higher numbers in diabetic compared to non-diabetic hosts, suggesting that hyperglycemia favors bacterial survival. Additionally, the bacterial load was higher in NOD mice, which have a compromised immune system, compared to C57Bl/6 mice. Our results reveal that high as well as low-virulent staphylococcal strains are able to cause soft tissue infections and to persist in diabetic humans and mice, suggesting a reason for the frequent and endangering infections in patients with diabetes.
Collapse
Affiliation(s)
- Lorena Tuchscherr
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany.
| | - Èva Korpos
- Institute of Physiological Chemistry and Pathobiochemistry, Germany; Cells-in-Motion Cluster of Excellence, University of Muenster, Muenster, Germany
| | - Hélène van de Vyver
- Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany
| | - Clais Findeisen
- Institute of Physiological Chemistry and Pathobiochemistry, Germany; Cells-in-Motion Cluster of Excellence, University of Muenster, Muenster, Germany
| | - Salome Kherkheulidze
- Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany
| | - Anke Siegmund
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | | | - Olaf Bach
- Surgery, Orthopedics and Traumatology, Special Trauma Surgery, Clinic of Weimar, Germany
| | - Martin Rindert
- Surgery, Orthopedics and Traumatology, Special Trauma Surgery, Clinic of Weimar, Germany
| | | | - Cord Sunderkötter
- Department of Translational Dermatoinfectiology, University of Muenster, Muenster and Department of Dermatology, University Hospital of Halle, Halle, Germany; Cells-in-Motion Cluster of Excellence, University of Muenster, Muenster, Germany
| | - Georg Peters
- Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany; Cells-in-Motion Cluster of Excellence, University of Muenster, Muenster, Germany
| | - Lydia Sorokin
- Institute of Physiological Chemistry and Pathobiochemistry, Germany; Cells-in-Motion Cluster of Excellence, University of Muenster, Muenster, Germany
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| |
Collapse
|
28
|
Neutralizing Alpha-Toxin Accelerates Healing of Staphylococcus aureus-Infected Wounds in Nondiabetic and Diabetic Mice. Antimicrob Agents Chemother 2018; 62:AAC.02288-17. [PMID: 29311091 DOI: 10.1128/aac.02288-17] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/03/2018] [Indexed: 12/26/2022] Open
Abstract
Staphylococcus aureus wound infections delay healing and result in invasive complications such as osteomyelitis, especially in the setting of diabetic foot ulcers. In preclinical animal models of S. aureus skin infection, antibody neutralization of alpha-toxin (AT), an S. aureus-secreted pore-forming cytolytic toxin, reduces disease severity by inhibiting skin necrosis and restoring effective host immune responses. However, whether therapeutic neutralization of alpha-toxin is effective against S. aureus-infected wounds is unclear. Herein, the efficacy of prophylactic treatment with a human neutralizing anti-AT monoclonal antibody (MAb) was evaluated in an S. aureus skin wound infection model in nondiabetic and diabetic mice. In both nondiabetic and diabetic mice, anti-AT MAb treatment decreased wound size and bacterial burden and enhanced reepithelialization and wound resolution compared to control MAb treatment. Anti-AT MAb had distinctive effects on the host immune response, including decreased neutrophil and increased monocyte and macrophage infiltrates in nondiabetic mice and decreased neutrophil extracellular traps (NETs) in diabetic mice. Similar therapeutic efficacy was achieved with an active vaccine targeting AT. Taken together, neutralization of AT had a therapeutic effect against S. aureus-infected wounds in both nondiabetic and diabetic mice that was associated with differential effects on the host immune response.
Collapse
|
29
|
Influence of multidrug resistant organisms on the outcome of diabetic foot infection. Int J Infect Dis 2018; 70:10-14. [PMID: 29476898 DOI: 10.1016/j.ijid.2018.02.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/08/2018] [Accepted: 02/13/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We described the clinical outcomes of the diabetic patients who had foot infections with multidrug resistant organisms. METHODS We included the patients with diabetic foot infections (DFI) from 19 centers, between May 2011 and December 2015. Infection was defined according to IDSA DFI guidelines. Patients with severe infection, complicated moderate infection were hospitalized. The patients were followed-up for 6 months after discharge. RESULTS In total, 791 patients with DFI were included, 531(67%) were male, median age was 62 (19-90). Severe infection was diagnosed in 85 (11%) patients. Osteomyelitis was diagnosed in 291(36.8%) patients. 536 microorganisms were isolated, the most common microorganisms were S. aureus (20%), P. aeruginosa (19%) and E. coli (12%). Methicillin resistance (MR) rate among Staphylococcus aureus isolates was 31%. Multidrug resistant bacteria were detected in 21% of P. aeruginosa isolates. ESBL (+) Gram negative bacteria (GNB) was detected in 38% of E. coli and Klebsiella isolates. Sixty three patients (8%) were re-hospitalized. Of the 791 patiens, 127 (16%) had major amputation, and 24 (3%) patients died. In multivariate analysis, significant predictors for fatality were; dialysis (OR: 8.3, CI: 1.82-38.15, p=0.006), isolation of Klebsiella spp. (OR:7.7, CI: 1.24-47.96, p=0.028), and chronic heart failure (OR: 3, CI: 1.01-9.04, p=0.05). MR Staphylococcus was detected in 21% of the rehospitalized patients, as the most common microorganism (p<0.001). CONCLUSION Among rehospitalized patients, methicillin resistant Staphylococcus infections was detected as the most common agent, and Klebsiella spp. infections were found to be significantly associated with fatality.
Collapse
|
30
|
Li X, Qi X, Yuan G, Ju S, Yu Z, Deng W, Liu Y, Li Y, Bu X, Ding M, Li Q, Guo X. Microbiological profile and clinical characteristics of diabetic foot infection in northern China: a retrospective multicentre survey in the Beijing area. J Med Microbiol 2018; 67:160-168. [PMID: 29293083 DOI: 10.1099/jmm.0.000658] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Xiangyan Li
- Department of Anti-Infection, The Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, PR China
| | - Xin Qi
- Department of Plastic Surgery and Burns, Peking University First Hospital, Beijing, PR China
| | - Geheng Yuan
- Department of Endocrinology, Peking University First Hospital, Beijing, PR China
| | - Shang Ju
- Department of Peripheral Vascular, Beijing University of Chinese Medicine, Dongzhimen Hospital, Beijing, PR China
| | - Zhengya Yu
- Department of General and Vascular Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, PR China
| | - Wei Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, PR China
| | - Yanjun Liu
- Department of Endocrinology, The 306th Hospital of PLA, Beijing, PR China
| | - Yufeng Li
- Department of Endocrinology, Beijing Pinggu Hospital, Beijing, PR China
| | - Xiujun Bu
- Department of Endocrinology, Beijing Fengtai Hospital, Beijing, PR China
| | - Mingchao Ding
- Peripheral Vascular Interventional, Aerospace Central Hospital, Beijing, PR China
| | - Quan Li
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, PR China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, PR China
| |
Collapse
|
31
|
Kwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections. Infect Chemother 2018; 50:11-20. [PMID: 29637748 PMCID: PMC5895826 DOI: 10.3947/ic.2018.50.1.11] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Indexed: 02/06/2023] Open
Abstract
In addition to being the prime factor associated with amputation, diabetic foot infections (DFIs) are associated with major morbidity, increasing mortality, and reduced quality of life. The choice of appropriate antibiotics is very important in order to reduce treatment failure, antimicrobial resistance, adverse events, and costs. We reviewed articles on microbiology and antimicrobial therapy and discuss antibiotic selection in Korean patients with DFIs. Similar to Western countries, Staphylococcus aureus is the most common pathogen, with Streptococcus, Enterococcus, Enterobacteriaceae and Pseudomonas also prevalent in Korea. It is recommended that antibiotics are not prescribed for clinically uninfected wounds and that empirical antibiotics be selected based on the clinical features, disease severity, and local antimicrobial resistance patterns. Narrow-spectrum oral antibiotics can be administered for mild infections and broad-spectrum parenteral antibiotics should be administered for some moderate and severe infections. In cases with risk factors for methicillin-resistant S. aureus or Pseudomonas, empirical antibiotics to cover each pathogen should be considered. The Health Insurance Review and Assessment Service standards should also be considered when choosing empirical antibiotics. In Korea, nationwide studies need to be conducted and DFI guidelines should be developed.
Collapse
Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery of Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
32
|
Aragón-Sánchez J, Lipsky BA. Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches. Expert Rev Anti Infect Ther 2017; 16:35-50. [PMID: 29231774 DOI: 10.1080/14787210.2018.1417037] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) has long been considered a complex infection that is both difficult to diagnose and treat, and is associated with a high rate of relapse and limb loss. Areas covered: DFO can usually be diagnosed by a combination of clinical evaluation, serum inflammatory markers and plain X-ray. When the results of these procedures are negative or contradictory, advanced imaging tests or bone biopsy may be necessary. Staphylococcus aureus remains the most frequent microorganism isolated from bone specimens, but infection is often polymicrobial. Antibiotic therapy, preferably with oral agents guided by results of bone culture, for a duration of no more than six weeks, appears to be as safe and effective as surgery in cases of uncomplicated forefoot DFO. Surgery (which should be limb-sparing when possible) is always required for DFO accompanied by necrotizing fasciitis, deep abscess, gangrene or in cases not responding (either clinically or radiographically) to apparently appropriate antibiotic treatment. Expert commentary: Research in the past decade has improved diagnosis and treatment of DFO, and most cases can now be managed with a 'conservative' approach, defined as treatment either exclusively with antibiotics or with surgery removing as little bone and soft tissue as necessary.
Collapse
Affiliation(s)
- Javier Aragón-Sánchez
- a Department of Surgery, Diabetic Foot Unit , La Paloma Hospital , Las Palmas de Gran Canaria , Spain
| | - Benjamin A Lipsky
- b Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA.,c Green Templeton College , University of Oxford , Oxford , UK
| |
Collapse
|
33
|
Chisman R, Lowry D, Saeed MA, Tiwari A, David MD. Prescribing antibiotics in diabetic foot infection: what is the role of initial microscopy and culture of tissue samples? . Int Wound J 2017; 14:685-690. [PMID: 27696697 PMCID: PMC7950145 DOI: 10.1111/iwj.12674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/18/2016] [Accepted: 08/21/2016] [Indexed: 12/21/2022] Open
Abstract
The aim of this study was to evaluate the role of microscopy, Gram stain and the culture of tissue samples in the antibiotic treatment of patients with diabetic foot infection. A retrospective review of patients with a diabetic foot infection was undertaken. Data analysed included the severity of infection, antibiotic prescribing patterns, microscopy and culture results. A total of 71 patients were included, from whom 114 tissue samples were collected. Gram stain results were in agreement with final culture results in 45·8% (n = 54) of samples. Overall sensitivity and specificity of the Gram stains were low (74·5% and 69·8%, respectively), although the specificity for Gram-negative rods was high (98·5%). The presence or absence of 'pus cells' on microscopy was a poor predictor of culture results. Empirical prescribing of antibiotics was in accordance with local policy in 31·1% of patients, improving to 86·8 % following culture results. Microscopy, a skilled laboratory procedure, was generally a poor predictor of tissue culture results. However, the presence of Gram-negative rods was suggestive of isolation in the culture of such organisms and could allow the early broadening of antibiotic treatment. Despite initial poor compliance of empirical antibiotic treatment regimens, prescribing was adjusted in light of culture results, suggesting these were important for clinicians.
Collapse
Affiliation(s)
- Robin Chisman
- College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Danielle Lowry
- Department of Vascular SurgeryUniversity Hospitals BirminghamBirminghamUK
| | - Mujahid A Saeed
- Department of DiabetesUniversity Hospitals BirminghamBirminghamUK
| | - Alok Tiwari
- Department of Vascular SurgeryUniversity Hospitals BirminghamBirminghamUK
| | - Miruna D David
- Department of Clinical MicrobiologyUniversity Hospitals BirminghamBirminghamUK
| |
Collapse
|
34
|
Bouvet C, Gjoni S, Zenelaj B, Lipsky BA, Hakko E, Uçkay I. Staphylococcus aureus soft tissue infection may increase the risk of subsequent staphylococcal soft tissue infections. Int J Infect Dis 2017; 60:44-48. [PMID: 28487239 DOI: 10.1016/j.ijid.2017.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/03/2017] [Accepted: 05/02/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Staphylococcus aureus is the most common cause of soft tissue infections. It is unknown, however, if a patient who has had such an infection is at greater risk for future soft tissue infections with S. aureus. METHODS We conducted an epidemiological survey of adult patients hospitalized in the only public hospital in Geneva for treatment (usually combined surgical and medical) of a soft tissue infection caused by S. aureus. By reviewing nursing and medical records from the emergency department and hospital wards, we assessed whether or not they developed any other soft tissue infections (excluding a recurrence) after or before the index one. RESULTS Among 1023 index episodes of soft tissue infections, 670 (65%) were caused by S. aureus, of which 47 were caused by methicillin-resistant strains (30 healthcare-associated and 17 community-acquired). The patients' median age was 51 years and 334 (34%) were immune-compromised. The median time span between the patient's first and last consultation (for any reason) in our hospital was 21.4 years (interquartile range, 10-30 years). In addition to their index infection, 124 patients (12%) developed a new nosocomial or community-acquired soft tissue infection. Among the index cases with an S. aureus infection, 92 (14%) had another soft tissue infection, compared to 32 (9%) who had a non-staphylococcal index infection (Pearson-χ2-test; p=0.03). Similarly, patients with an index S. aureus infection, compared to those with a non-S. aureus infection, had a higher rate of another soft tissue infection caused by S. aureus (χ2-test; p<0.01). In multivariate analysis, an index infection due to S. aureus shows a high association to further S. aureus soft tissue infections (logistic regression; odds ratio 2.5, 95% confidence interval 1.4-4.6). CONCLUSION Among adult patients hospitalised for a soft tissue infection, those infected with S. aureus (compared with other pathogens) may be at higher risk of a subsequent soft tissue infection, particularly with S. aureus.
Collapse
Affiliation(s)
- Cindy Bouvet
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
| | - Shpresa Gjoni
- Division of General Medical Rehabilitation, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
| | - Besa Zenelaj
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland; Division of Medical Sciences, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Elif Hakko
- Anadolu Sağlık Hospital, Istanbul, Turkey
| | - Ilker Uçkay
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland; Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland.
| |
Collapse
|
35
|
Lebowitz D, Gariani K, Kressmann B, Dach EV, Huttner B, Bartolone P, Lê N, Mohamad M, Lipsky BA, Uçkay I. Are antibiotic-resistant pathogens more common in subsequent episodes of diabetic foot infection? Int J Infect Dis 2017; 59:61-64. [PMID: 28450198 DOI: 10.1016/j.ijid.2017.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/08/2017] [Accepted: 04/13/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND After antibiotic therapy of an initial diabetic foot infection (DFI), pathogens isolated from subsequent episodes might become more resistant to commonly prescribed antibiotics. If so, this might require a modification of the current recommendations for the selection of empiric antibiotic therapy. This study investigated whether the Infectious Diseases Society of America (IDSA) DFI guideline recommendations should be modified based on the number of past DFI episodes. METHODS This was a single-centre retrospective cohort survey of DFI patients seen during the years 2010 to 2016. RESULTS A total 1018 episodes of DFI in 482 adult patients were identified. These patients were followed-up for a median of 3.3 years after the first DFI episode. The total number of episodes was 2257 and the median interval between recurrent episodes was 7.6 months. Among the recurrent DFIs, the causative pathogens were the same as in the previous episode in only 43% of cases (158/365). Staphylococcus aureus was the predominant pathogen in all episodes (range 1 to 13 episodes) and was not more prevalent with the increasing number of episodes. DFIs were treated with systemic antibiotics for a median duration of 20 days (interquartile range 11-35 days). Overall, there was no significant increase in the incidence of antibiotic resistance to methicillin, rifampicin, clindamycin, or ciprofloxacin over the episodes (Pearson's Chi-square test p-values of 0.76, 1.00, 0.06, and 0.46, respectively; corresponding p-values for trend of 0.21, 0.27, 0.38, and 0.08, respectively). CONCLUSIONS After the successful treatment of a DFI, recurrent episodes are frequent. A history of a previous DFI episode did not predict a greater likelihood of any antibiotic-resistant isolate in subsequent episodes. Thus, broadening the spectrum of empiric antibiotic therapy for recurrent episodes of DFI does not appear necessary.
Collapse
Affiliation(s)
- Dan Lebowitz
- Service of General Internal Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benedikt Huttner
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Placido Bartolone
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nam Lê
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Morad Mohamad
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| |
Collapse
|
36
|
Ashong CN, Raheem SA, Hunter AS, Mindru C, Barshes NR. Methicillin-Resistant Staphylococcus aureus in Foot Osteomyelitis. Surg Infect (Larchmt) 2016; 18:143-148. [PMID: 27898266 DOI: 10.1089/sur.2016.165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Conflicting studies exist regarding the impact of methicillin-resistant Staphylococcus aureus (MRSA) on increased time to wound healing, future need for surgical procedures, and likelihood of treatment failure in patients with diabetic foot osteomyelitis. The purpose of this study is to determine the overall significance of MRSA in predicting treatment failure in bone infections of the foot and to determine an appropriate pre-operative and empiric post-operative antibiotic regimen. PATIENTS AND METHODS Patients presenting with an initial episode of "probable" or "definite" foot osteomyelitis were included for review and analysis if the following criteria were met: (1) Osteomyelitis occurred in the foot (i.e., distal to the malleoli of the ankle); episodes occurring above the ankle were excluded. (2) Patients received either no antibiotics or only oral antibiotics for long-term treatment; episodes managed with long-term parenteral antibiotics were excluded. (3) The infection was managed initially with medical therapy or conservative surgical therapy; episodes managed with major (above-ankle) amputation as the initial treatment were excluded. The primary objective of this study was to assess whether episodes of foot osteomyelitis associated with MRSA resulted in treatment failure more frequently than not. RESULTS Of 178 episodes included in the study, 50 (28.1%) episodes had treatment failure. Median time-to-treatment failure was 60 days (range 7-598 days). In 28.1% (9/32 episodes) in which treatment failure occurred and 39.0% (41/105) episodes in which no treatment failure occurred, MRSA was present. The presence of MRSA was not significantly associated with treatment failure (p = 0.99). CONCLUSIONS The presence of MRSA in bone culture and whether antibiotic use had anti-MRSA activity was not associated with increased treatment failure of diabetic foot osteomyelitis in our institution. Empiric antibiotic coverage of MRSA may not be necessary for many patients presenting with foot osteomyelitis.
Collapse
Affiliation(s)
- Chester N Ashong
- 1 Department of Pharmacy, Michael E. DeBakey Veterans Affairs Medical Center . Houston, Texas
| | - Shazia A Raheem
- 1 Department of Pharmacy, Michael E. DeBakey Veterans Affairs Medical Center . Houston, Texas
| | - Andrew S Hunter
- 1 Department of Pharmacy, Michael E. DeBakey Veterans Affairs Medical Center . Houston, Texas
| | - Cezarina Mindru
- 2 Department of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center . Houston, Texas
| | - Neal R Barshes
- 3 Division of Vascular and Endovascular Surgery, Michael E. DeBakey Department of Surgery Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center , Houston, Texas
| |
Collapse
|
37
|
Robineau O, Nguyen S, Senneville E. Optimising the quality and outcomes of treatments for diabetic foot infections. Expert Rev Anti Infect Ther 2016; 14:817-27. [PMID: 27448992 DOI: 10.1080/14787210.2016.1214072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients. AREAS COVERED We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.
Collapse
Affiliation(s)
- O Robineau
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - S Nguyen
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - E Senneville
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| |
Collapse
|
38
|
Dunyach-Remy C, Ngba Essebe C, Sotto A, Lavigne JP. Staphylococcus aureus Toxins and Diabetic Foot Ulcers: Role in Pathogenesis and Interest in Diagnosis. Toxins (Basel) 2016; 8:toxins8070209. [PMID: 27399775 PMCID: PMC4963842 DOI: 10.3390/toxins8070209] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/17/2022] Open
Abstract
Infection of foot ulcers is a common, often severe and costly complication in diabetes. Diabetic foot infections (DFI) are mainly polymicrobial, and Staphylococcus aureus is the most frequent pathogen isolated. The numerous virulence factors and toxins produced by S. aureus during an infection are well characterized. However, some particular features could be observed in DFI. The aim of this review is to describe the role of S. aureus in DFI and the implication of its toxins in the establishment of the infection. Studies on this issue have helped to distinguish two S. aureus populations in DFI: toxinogenic S. aureus strains (harboring exfoliatin-, EDIN-, PVL- or TSST-encoding genes) and non-toxinogenic strains. Toxinogenic strains are often present in infections with a more severe grade and systemic impact, whereas non-toxinogenic strains seem to remain localized in deep structures and bone involving diabetic foot osteomyelitis. Testing the virulence profile of bacteria seems to be a promising way to predict the behavior of S. aureus in the chronic wounds.
Collapse
Affiliation(s)
- Catherine Dunyach-Remy
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Christelle Ngba Essebe
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
| | - Albert Sotto
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Jean-Philippe Lavigne
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| |
Collapse
|
39
|
Hatipoglu M, Mutluoglu M, Turhan V, Uzun G, Lipsky BA, Sevim E, Demiraslan H, Eryilmaz E, Ozuguz C, Memis A, Ay H, Arda B, Uysal S, Motor VK, Kader C, Erturk A, Coskun O, Duygu F, Guler S, Altay FA, Ogutlu A, Bolukcu S, Yildiz S, Kandemir O, Aslaner H, Polat A, Karahocagil MK, Yasar KK, Sehmen E, Kilic S, Sunbul M, Gencer S, Bozkurt F, Yanik T, Oztoprak N, Batirel A, Sozen H, Kilic I, Celik I, Ay B, Tosun S, Kadanali A, Çomoglu S, Denk A, Hosoglu S, Aydin O, Elaldi N, Akalin S, Kandemir B, Akbulut A, Demirdal T, Balik R, Azak E, Sengoz G. Causative pathogens and antibiotic resistance in diabetic foot infections: A prospective multi-center study. J Diabetes Complications 2016; 30:910-6. [PMID: 26965794 DOI: 10.1016/j.jdiacomp.2016.02.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/27/2016] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Abstract
AIM Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials. METHODS The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate (NCT02026830). RESULTS A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group. CONCLUSIONS Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.
Collapse
Affiliation(s)
- Mustafa Hatipoglu
- Department of Infectious Diseases and Clinical Microbiology, Canakkale Military Hospital, Canakkale, Turkey
| | - Mesut Mutluoglu
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Vedat Turhan
- Department of Infectious Diseases and Clinical Microbiology, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey
| | - Gunalp Uzun
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland; Division of Medical Sciences, Green Templeton College, University of Oxford, Oxford, UK
| | - Erol Sevim
- Department of Infectious Diseases and Clinical Microbiology, Sifa University Medical Faculty Izmir, Turkey
| | - Hayati Demiraslan
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Esma Eryilmaz
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Cem Ozuguz
- Department of Infectious Diseases and Clinical Microbiology, Eskisehir Military Hospital, Eskisehir, Turkey
| | - Ali Memis
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Hakan Ay
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Bilgin Arda
- Department of Infectious Diseases and Clinical Microbiology, Ege University School of Medicine, Izmir, Turkey
| | - Serhat Uysal
- Department of Infectious Diseases and Clinical Microbiology, Ege University School of Medicine, Izmir, Turkey
| | - Vicdan Koksaldi Motor
- Department of Infectious Diseases and Clinical Microbiology, Mustafa Kemal University Medical School, Hatay, Turkey
| | - Cigdem Kader
- Department of Infectious Diseases and Clinical Microbiology, Bozok University School of Medicine, Yozgat, Turkey
| | - Ayse Erturk
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Omer Coskun
- Department of Infectious Diseases and Clinical Microbiology, Gulhane Medical Academy, Ankara, Turkey
| | - Fazilet Duygu
- Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University Medical School, Tokat, Turkey
| | - Selma Guler
- Department of Infectious Diseases and Clinical Microbiology, Sutcu Imam University, School of Medicine, Kahramanmaras, Turkey
| | - Fatma Aybala Altay
- Department of Infectious Diseases and Clinical Microbiology, Diskapi Yildirim Beyazit Training & Research Hospital, Ankara, Turkey
| | - Aziz Ogutlu
- Department of Infectious Diseases and Clinical Microbiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Sibel Bolukcu
- Department of Infectious Diseases and Clinical Microbiology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Senol Yildiz
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ozlem Kandemir
- Department of Infectious Diseases and Clinical Microbiology, Mersin University School of Medicine, Mersin, Turkey
| | - Halide Aslaner
- Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Training and Research Hospital Ankara, Turkey
| | - Arife Polat
- Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Training and Research Hospital Ankara, Turkey
| | - Mustafa K Karahocagil
- Department of Infectious Diseases and Clinical Microbiology, Yuzuncuyil University School of Medicine, Van, Turkey
| | - Kadriye Kart Yasar
- Department of Infectious Diseases and Clinical Microbiology Istanbul Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Emine Sehmen
- Department of Infectious Diseases and Clinical Microbiology, Samsun Training and Research Hospital Samsun, Turkey
| | - Sirri Kilic
- Department of Infectious Diseases and Clinical Microbiology, Samsun Training and Research Hospital Samsun, Turkey
| | - Mustafa Sunbul
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Serap Gencer
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Fatma Bozkurt
- Department of Infectious Diseases and Clinical Microbiology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Tugba Yanik
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ayse Batirel
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Hamdi Sozen
- Department of Infectious Disease, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Inci Kilic
- Department of Infectious Disease, Education and Research Hospital, Kayseri, Turkey
| | - Ilhami Celik
- Department of Infectious Disease, Education and Research Hospital, Kayseri, Turkey
| | - Bengisu Ay
- Department of Infectious Diseases and Clinical Microbiology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Selma Tosun
- Department of Infectious Diseases and Clinical Microbiology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Ayten Kadanali
- Department of Infectious Diseases and Clinical Microbiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Senol Çomoglu
- Department of Infectious Diseases and Clinical Microbiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Affan Denk
- Department of Infectious Diseases and Clinical Microbiology, Firat University School of Medicine, Elazig, Turkey
| | - Salih Hosoglu
- Department of Infectious Diseases and Clinical Microbiology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Ozlem Aydin
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Nazif Elaldi
- Department of Infectious Diseases and Clinical Microbiology, Cumhuriyet University Medical School, Sivas, Turkey
| | - Serife Akalin
- Department of Infectious Diseases and Clinical Microbiology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Bahar Kandemir
- Department of Infectious Diseases and Clinical Microbiology, Necmettin Erbakan University, Konya, Turkey
| | - Ayhan Akbulut
- Department of Infectious Diseases and Clinical Microbiology, Firat University School of Medicine, Elazig, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Recep Balik
- Department of Infectious Diseases and Clinical Microbiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Emel Azak
- Department of Infectious Diseases, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Gonul Sengoz
- Department of Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
40
|
Akhi MT, Ghotaslou R, Memar MY, Asgharzadeh M, Varshochi M, Pirzadeh T, Alizadeh N. Frequency of MRSA in diabetic foot infections. Int J Diabetes Dev Ctries 2016. [DOI: 10.1007/s13410-016-0492-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
41
|
Mottola C, Semedo-Lemsaddek T, Mendes JJ, Melo-Cristino J, Tavares L, Cavaco-Silva P, Oliveira M. Molecular typing, virulence traits and antimicrobial resistance of diabetic foot staphylococci. J Biomed Sci 2016; 23:33. [PMID: 26952716 PMCID: PMC4782296 DOI: 10.1186/s12929-016-0250-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/23/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Diabetes mellitus is a major chronic disease that continues to increase significantly. One of the most important and costly complications of diabetes are foot infections that may be colonized by pathogenic and antimicrobial resistant bacteria, harboring several virulence factors, that could impair its successful treatment. Staphylococcus aureus is one of the most prevalent isolate in diabetic foot infections, together with aerobes and anaerobes. METHODS In this study, conducted in the Lisbon area, staphylococci isolated (n = 53) from diabetic foot ulcers were identified, genotyped and screened for virulence and antimicrobial resistance traits. Genetic relationship amongst isolates was evaluated by pulsed-field-gel-electrophoresis with further multilocus sequence typing of the identified pulsotypes. PCR was applied for detection of 12 virulence genes and e-test technique was performed to determine minimal inhibitory concentration of ten antibiotics. RESULTS Among the 53 isolates included in this study, 41 Staphylococcus aureus were identified. Staphylococcal isolates were positive for intercellular adhesins icaA and icaD, negative for biofilm associated protein bap and pantone-valentine leucocidin pvl. S. aureus quorum sensing genes agrI and agrII were identified and only one isolate was positive for toxic shock syndrome toxin tst. 36 % of staphylococci tested were multiresistant and higher rates of resistance were obtained for ciprofloxacin and erythromycin. Clonality analysis revealed high genomic diversity and numerous S. aureus sequence types, both community- and hospital-acquired, belonging mostly to clonal complexes CC5 and C22, widely diffused in Portugal nowadays. CONCLUSIONS This study shows that diabetic foot ulcer staphylococci are genomically diverse, present resistance to medically important antibiotics and harbour virulence determinants. These properties suggest staphylococci can contribute to persistence and severity of these infections, leading to treatment failure and to the possibility of transmitting these features to other microorganisms sharing the same niche. In this context, diabetic patients may become a transmission vehicle for microorganisms' clones between community and clinical environments.
Collapse
Affiliation(s)
- Carla Mottola
- Centro de Investigação Interdisciplinar em Sanidade Animal, Faculdade de Medicina Veterinária, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
| | - Teresa Semedo-Lemsaddek
- BioFIG, Centro para a Biodiversidade, Genómica Integrativa e Funcional, Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016, Lisbon, Portugal.
| | - João J Mendes
- Departamento de Medicina Interna, Hospital de Santa Marta/Centro Hospitalar de Lisboa Central, EPE, Rua de Santa Marta, 1169-024, Lisbon, Portugal.
| | - José Melo-Cristino
- Faculdade de Medicina, Universidade de Lisboa, Instituto de Microbiologia, Avenida Prof. Egas Moniz, 1649-028, Lisbon, Portugal.
| | - Luís Tavares
- Centro de Investigação Interdisciplinar em Sanidade Animal, Faculdade de Medicina Veterinária, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
| | - Patrícia Cavaco-Silva
- TechnoPhage, S.A., Avenida Prof. Egas Moniz, 1600-190, Lisbon, Portugal.
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Ciências da Saúde Egas Moniz, Via Alternativa ao Monte de Caparica, 2829-511, Caparica, Portugal.
| | - Manuela Oliveira
- Centro de Investigação Interdisciplinar em Sanidade Animal, Faculdade de Medicina Veterinária, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
| |
Collapse
|
42
|
Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJG. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:45-74. [PMID: 26386266 DOI: 10.1002/dmrr.2699] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Benjamin A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | | | - Mathew Diggle
- Nottingham University Hospitals Trust, Nottingham, UK
| | - John Embil
- University of Manitoba, Winnipeg, MB, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Lawrence Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | | | | | - Suzanne Van Asten
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
- VU University Medical Centre, Amsterdam, The Netherlands
| | | |
Collapse
|
43
|
Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis 2015; 40:81-91. [DOI: 10.1016/j.ijid.2015.09.023] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 12/21/2022] Open
|
44
|
Commons RJ, Robinson CH, Gawler D, Davis JS, Price RN. High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study). Diabetes Res Clin Pract 2015; 110:147-57. [PMID: 26453263 PMCID: PMC4684095 DOI: 10.1016/j.diabres.2015.09.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/07/2015] [Accepted: 09/12/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The risk of diabetes mellitus is increasing worldwide, and is particularly high in Indigenous Australians. Complicated foot infection is one of the most common sequelae of diabetes. We describe the incidence and associations of Indigenous and non-Indigenous inpatients with diabetic foot infections at Royal Darwin Hospital. METHODS All adult Royal Darwin Hospital inpatients with diabetic foot infections were enrolled prospectively from September 2012 to November 2013. Incidence, demographics, microbiology, management and clinical outcomes were analysed by Indigenous status, and association with methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa. RESULTS There were 245 separate hospital admissions in 177 patients with an incidence of 79 admissions per 100,000 person years. Patients occupied a mean of 19.4 hospital beds each day. Compared to the non-Indigenous population, Indigenous patients had a greater incidence of admission (Rate Ratio (RR)=5.1, [95%CI=3.8, 7.0]), were younger (mean difference of 11.1 years; p<0.001), and more likely to undergo major and minor amputations (RR=4.1 [95%CI=1.6, 10.7], and 6.2 [95%CI=3.5, 11.1] respectively). Non-multiresistant methicillin resistant S. aureus was present in 44.7% of wounds from Indigenous patients versus 20.6% of non-Indigenous patients (Odds Ratio (OR)=3.1, [95%CI=1.5, 6.4]), whereas P. aeruginosa presence was significantly lower (15.8% versus 46.0%; OR=0.22; [95%CI=0.11, 0.45]). Methicillin resistant S. aureus or P. aeruginosa infections were associated with longer antibiotic courses and durations of stay. CONCLUSIONS This study highlights a rising burden of diabetic foot infections in the Top End of Australia, with a four-fold increase in bed days since 2002 and an overrepresentation in the Indigenous population.
Collapse
Affiliation(s)
- Robert J Commons
- Department of Infectious Diseases, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia.
| | - Claire H Robinson
- High Risk Foot Service, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia
| | - David Gawler
- Division of Surgery, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia
| | - Joshua S Davis
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Northern Territory, Australia
| | - Ric N Price
- Department of Infectious Diseases, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia; Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Northern Territory, Australia; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, OX3 7LJ, UK
| |
Collapse
|
45
|
Charles PGP, Uçkay I, Kressmann B, Emonet S, Lipsky BA. The role of anaerobes in diabetic foot infections. Anaerobe 2015; 34:8-13. [PMID: 25841893 DOI: 10.1016/j.anaerobe.2015.03.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/24/2015] [Indexed: 12/25/2022]
Abstract
Diabetic foot infections (DFI) are a common cause of morbidity and, on occasion, even mortality. Infection can be either mono- or polymicrobial, with a wide variety of potential pathogens. Anaerobes may be involved, particularly in wounds that are deeper or more chronic, and are more frequently identified when using modern molecular techniques, such as 16s PCR and pyrosequencing. It remains unclear whether the presence of anaerobes in DFI leads to more severe manifestations, or if these organisms are largely colonizers associated with the presence of greater degrees of tissue ischemia and necrosis. Commonly used empiric antibiotic therapy for diabetic foot infections is generally broad-spectrum and usually has activity against the most frequently identified anaerobes, such as Peptostreptococcus and Bacteroides species. Adequate surgical debridement and, when needed, foot revascularization may be at least as important as the choice of antibiotic to achieve a successful treatment outcome.
Collapse
Affiliation(s)
- Patrick G P Charles
- Infectious Diseases Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Parkville, Australia.
| | - Ilker Uçkay
- Infectious Diseases Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Benjamin Kressmann
- Infectious Diseases Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Stéphane Emonet
- Infectious Diseases Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Laboratory of Bacteriology, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A Lipsky
- Infectious Diseases Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Medical Sciences (Infectious Diseases), University of Oxford, Oxford, UK
| |
Collapse
|
46
|
Abbas M, Uçkay I, Lipsky BA. In diabetic foot infections antibiotics are to treat infection, not to heal wounds. Expert Opin Pharmacother 2015; 16:821-32. [PMID: 25736920 DOI: 10.1517/14656566.2015.1021780] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diabetic foot ulcers, especially when they become infected, are a leading cause of morbidity and may lead to severe consequences, such as amputation. Optimal treatment of these diabetic foot problems usually requires a multidisciplinary approach, typically including wound debridement, pressure off-loading, glycemic control, surgical interventions and occasionally other adjunctive measures. AREAS COVERED Antibiotic therapy is required for most clinically infected wounds, but not for uninfected ulcers. Unfortunately, clinicians often prescribe antibiotics when they are not indicated, and even when indicated the regimen is frequently broader spectrum than needed and given for longer than necessary. Many agents are available for intravenous, oral or topical therapy, but no single antibiotic or combination is optimal. Overuse of antibiotics has negative effects for the patient, the health care system and society. Unnecessary antibiotic therapy further promotes the problem of antibiotic resistance. EXPERT OPINION The rationale for prescribing topical, oral or parenteral antibiotics for patients with a diabetic foot wound is to treat clinically evident infection. Available published evidence suggests that there is no reason to prescribe antibiotic therapy for an uninfected foot wound as either prophylaxis against infection or in the hope that it will hasten healing of the wound.
Collapse
Affiliation(s)
- Mohamed Abbas
- University of Geneva, Geneva University Hospitals and Medical School, Service of Infectious Diseases , 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14 , Switzerland +41 22 372 33 11 ;
| | | | | |
Collapse
|